User experiences of structured stakeholder engagement to consider transferability: The TRANSFER approach

Abstract Background Systematic reviews are increasingly used to inform decision‐making in health, education, social care and environmental protection. However, decision makers still experience barriers to using reviews, including not knowing how findings might translate to their own contexts, and lack of collaboration with systematic review authors. The TRANSFER approach is a novel method that aims to support review authors to systematically and transparently collaborate with stakeholders to consider context and the transferability of review findings from the beginning of the review process. Such collaboration is intended to improve the usefulness and relevance of review findings for decision makers. Objectives We aim to explore the user experience of the TRANSFER approach conversation guide, and in doing so gain a better understanding of the role and perceived value of stakeholder engagement in systematic reviews for informed decision‐making. Methods We conducted four user tests of groups using the guide, organized around simulated meetings between review authors and stakeholders. Review authors led the meeting using the TRANSFER approach conversation guide. We audio‐recorded and observed the meetings, collected feedback forms and conducted semi‐structured interviews with review authors following the meeting. We analysed the data using framework analysis to examine the user experience of the TRANSFER approach conversation guide and of stakeholder engagement more generally. Results Seventeen participants in four user groups participated in the user tests. Most participants were generally positive toward the structured approach using the conversation guide, and felt it would be useful in systematic review projects. We observed examples of misunderstanding of the terminology included in the guide, and received multiple suggestions for how to make the conversation guide more user friendly. We observed numerous challenges related to the hypothetical nature of a user test, including lack of familiarity with the review question/topic among participants and lack of preparation for the meeting. Conclusions Review authors and stakeholders are positive toward using a structured approach to guide collaboration within the context of a systematic review. The TRANSFER conversation guide helps participants to discuss the review question and context in a structured way. Such structured collaboration could help to improve the usefulness and relevance of systematic reviews for decision making by improving the review question, inclusion criteria and consideration of transferability of review findings. The conversation guide needs to be modified to improve user experience. Further research is needed to explore stakeholder collaboration and the use of the TRANSFER conversation guide in systematic review processes.

review. The TRANSFER conversation guide helps participants to discuss the review question and context in a structured way. Such structured collaboration could help to improve the usefulness and relevance of systematic reviews for decision making by improving the review question, inclusion criteria and consideration of transferability of review findings. The conversation guide needs to be modified to improve user experience. Further research is needed to explore stakeholder collaboration and the use of the TRANSFER conversation guide in systematic review processes.

| BACKGROUND
Decision makers in the fields of health, education, social welfare, and environmental protection are increasingly aiming to draw on the best available research evidence to inform their decision-making processes (Dicks et al., 2017;Gough et al., 2011;Lundahl et al., 2009;Yost et al., 2014). Systematic reviews, widely viewed as the best source of such evidence, are designed to make the available evidence easier to find and use (Gopalakrishnan & Ganeshkumar, 2013).
However, barriers to use persist (Oliver et al., 2014;Tricco et al., 2016;Wallace et al., 2012). In this study, we present an evaluation of a novel approach to address two of the perceived barriers to the use of research evidence in decision-making processes, specifically, collaboration between systematic review authors and decision makers and the consideration of context of review findings.

| Barriers and facilitators to using systematic review findings in decision making
Methods that support the use of findings from systematic reviews in decision making have evolved significantly over the past decades.
Databases where reviews are published have become more physically accessible (e.g., through sources like the Cochrane Library; www. cochranelibrary.com), publishers have developed more user-friendly formats to present findings (e.g., Supporting Policy-relevant Reviews and Trial (SUPPORT) summaries; Rosenbaum et al., 2011) and researchers have developed robust frameworks that help decision making groups, such as guideline panels, consider the most important decision criteria and related research evidence in their decision making processes (Evidence-to-Decision Framework (EtD) (Lavis et al., 2009;Moberg et al., 2018;Rosenbaum et al., 2018). However, a number of real and perceived barriers to the use of evidence in decision making remain, including people's lack of skills to find and interpret evidence, available time, and knowledge among decision makers regarding the function of systematic reviews (Innvaer et al., 2002;Oliver et al., 2014;Tricco et al., 2016). Studies have also identified activities that may facilitate the use of evidence, including improved consideration of context, and improved collaboration between stakeholders and researchers (Oliver et al., 2014;Rosenbaum et al., 2011;Tricco et al., 2016). For the purpose of this study, the term stakeholders refers to anyone with an interest in the findings from a systematic review, including patients and service users, patients and the public, health care practitioners, policymakers and other decision makers.

| Considering context and the transferability of review findings
An intervention's implementation context may influence how it works (Shepperd et al., 2009). Context is therefore an important consideration when evaluating, or exploring experiences and perceptions, of an intervention in a systematic review. For the purpose of this study, context refers to 'the multi-level environment (not just the physical setting) in which an intervention is developed, implemented and assessed: the circumstances that interact, influence and even modify the implementation of an intervention and its effects' (Munthe-Kaas et al., 2020). Most systematic reviews include studies from different contexts that may vary according to geography, politics and/or culture (Lewin et al., 2017). Synthesized findings, based on data from studies that may have been conducted in a variety of contexts, may pose problems when people begin to consider the transferability (sometimes referred to as applicability, directness, relevance, etc.) of review findings to a local decisionmaking context. Decisions makers may question whether findings from a systematic review are relevant for their context. There is general consensus in the literature that 'the real or perceived failure of reviews to address relevant questions, contextualize the findings, or make actionable policy recommendations' can inhibit the use of systematic reviews in evidence-informed decision making (Chambers et al., 2011;Innvaer et al., 2002;Lavis et al., 2005;Petticrew, 2004;Sheldon, 2005). This is perhaps particularly relevant for interventions that are more complex and which are comprised of 'a number of separate elements which seem essential to the proper functioning of the interventions although the "active ingredient" of the intervention that is effective is difficult to specify' (BUK Medical Research Council). Improved collaboration with stakeholders, including decision makers, may be one way by which to address questions about context and transferability of review findings.

| Collaboration between stakeholders and review authors in conducting reviews
Stakeholder engagement in systematic reviews has long been advocated by researchers and stakeholders alike (Cottrell et al., 2014;Lavis et al., 2005;Sakala et al., 2001;Wale et al., 2010). There is a perceived 'gulf between decision makers and researchers, which prevent[s] the production of research from feeding into decision making processes' (Orton et al., 2011). Contact and collaboration between researchers and decision makers has been touted as both a barrier when absent, and a facilitator when present, to the use of review findings in decision-making. Numerous studies have extolled the potential benefits of stakeholder engagement, including production of more useful and relevant systematic reviews (Cottrell et al., 2014;Sakala et al., 2001;Wale et al., 2010) (Aloe et al., 2020;Pollock et al., 2018). Engaging with stakeholders is considered critical for defining and ensuring a common understanding of the review question and what it seeks to answer, understanding the review contexts and improving stakeholder buy-in, as they may sit with a great deal of expertise which may otherwise be unavailable or difficult to obtain (Cottrell et al., 2014;Esmail et al., 2015). Despite this enthusiasm, there is little published literature evaluating stakeholder engagement in research activities generally (Esmail et al., 2015). There are however, numerous studies calling for training materials, and examples of how to support stakeholder engagement in systematic reviews (Pollock et al., 2018).
Specifically, there is currently a lack of practical guidance on how researchers can effectively collaborate with stakeholders to systematically and transparently consider context and the transferability of review findings (Burchett et al., 2018;Burford et al., 2013;Gruen et al., 2005).

| The TRANSFER approach
TRANSFER approach aims to 'support … collaboration between review authors and stakeholders from the beginning of the review process to systematically and transparently consider factors that may influence the transferability of systematic review findings' (Munthe-Kaas et al., 2020). The main tenets of the TRANSFER framework are: (a) close collaboration between review authors and stakeholders, starting with the development of the review question, and (b) recognition that various stakeholders' expertise and contributions in the development of the review question are necessary for improving our consideration of context in systematic reviews. The TRANSFER approach consists of guidance for review authors, including guidance on: how to organize a meeting with stakeholders to define the population, intervention, comparison and outcomes to be examined in the review (using the PICO template) how to discuss and prioritize factors that may impact how transferable the studies are to the specified context (transferability factors) (Munthe-Kaas et al., 2020) (using the TRANSFER Conversation guide) how to define the local context of interest (using the TRANSFER Characteristics of context template), and; how to assess the transferability of a review finding from one context to another (i.e. will the intervention have the same effect/ be experienced in the same way for people in the decision making context if the data comes from studies where the context is substantially different according to the identified transferability factor(s)?) The TRANSFER approach is intended to help review authors to identify factors that may influence the transferability of a review finding to a local decision making context. Identified transferability factors should be considered to be hypotheses, and can include factors related to geopolitical climate or social or cultural values.
Review authors can use the identified transferability factors to inform subgroup analyses later in the review to assess whether a review finding is likely to be transferable to the review context. See  for more details on the TRANSFER approach and how it was developed . See Table 1 for an example illustrating how the TRANSFER approach could support review authors to systematically consider how contextual factors could influence the transferability of review findings to the context of interest.
1.5 | User testing to explore user experience of the TRANSFER approach User testing (also referred to as usability testing) refers to a research method where the goal is to expose areas of improvement in the design of a service, system or product to improve the products next iteration (Rosenbaum et al., 2008). Part of this method includes exploring users' experience of using a product, in this case the TRANSFER approach. The term 'user experience' refers to 'all the aspects of how people use an interactive product' (Alben, 1996). It is 'a consequence of a user's internal state (predispositions, expectations, needs, motivation, mood, etc.), the characteristics of the designed system (e.g., complexity, purpose, usability, functionality, etc.) and the context (or the environment) within which the interaction occurs (e.g. organizational/social setting, meaningfulness of the activity, voluntariness of use, etc.)' (Hassenzahl & Tractinsky, 2006). By exploring user experience of the TRANSFER approach, we hope to better understand user needs and contexts, make appropriate revisions, and attempt to optimize the methods described in the approach.

| AIM
Our study aimed to explore the user experience of the TRANSFER approach conversation guide from the perspective of the systematic review team and the stakeholders who have an interest in using the MUNTHE-KAAS ET AL. findings from a systematic review. A secondary aim was to gain a better understanding of the role of stakeholder engagement in systematic reviews, and stakeholders perceived value of this engagement, for informed decisionmaking.

| User-centred development
We employed a user-centred design approach in this study. Usercentred design, sometimes called human-centred design, is an approach to developing a product, service or system that puts the users' and other stakeholders' needs at the centre of the development (International Organization for Standardization, 2010). Two key characteristics of this approach are: (1) development that is based on an explicit understanding of users' needs and (2) an iterative process that entails creating or improving a prototype, exploring peoples' experiences of that prototype while carrying out tasks, identifying areas for improvements, and repeating the cycle.

| User testing method
To understand users' needs related to TRANSFER, we explored their user experiences of the tool by combining several methods. At the core we drew on a method called 'user testing'-a study design commonly applied in design development (Chisnell & Rubin, 2008) to understand people's ability to carry out desired tasks with a product or service.
We employed a 'constructive interaction with think-aloud' method (Als et al., 2005;Kahler et al., 2000;Van den Haak et al., 2004). This involved participants working together using the TRANSFER approach while we observed and captured their concurrent think-aloud reflections of what they were thinking and feeling.
From now on, we will refer to these sessions as 'group user tests'. We followed up these group user tests immediately with individual semistructured interviews employing retrospective think-aloud and written participant feedback.

| Participant selection
We used a purposive sampling method to identify participants. For each group user test we aimed to include at least: (a) two participants who had experience conducting systematic reviews (effectiveness reviews in three user tests, and qualitative evidence synthesis in one user test), and (b) two participants who were considered to be stakeholders in a review process (including policy makers, guideline panel members, other decision makers) and who were familiar with using the findings from or commissioning systematic reviews. We sent email invitations to systematic review authors from research institutes in Norway and policy makers from the Norwegian directorates of Health, Integration and Diversity, and Children, Youth and Family Affairs. Test participants were not rewarded financially but did receive reimbursement for travel costs when requested.

| Data collection
Each group user test was made up of a meeting scenario, feedback forms and semi-structured interviews with review authors.

| Before the user tests
Before each group user test, we sent the following documents and information via email to systematic review authors: a. TRANSFER approach guidance for systematic review authors.
T A B L E 1 Example illustrating when context matters in a decision-making process Example of when context matters: You are commissioned to conduct a systematic review on the effect of having a labour companion during birth in a medical facility. The review findings will inform global guidelines, and is intended to be adapted and used by individual countries. The review authors find that labour companionship has positive effects for mother and child. The review authors conduct separate subgroup analyses for high and middle-income contexts and find no substantial differences in effect.
When the intervention is implemented across a variety of settings, it becomes evident that the positive effects from the review are not seen in all contexts. Decision makers in certain settings hypothesize that the review finding does not transfer to their settings because the context of their settings differs substantially from the contexts of the studies that contribute data to the review findings. Specifically, the studies included in the review come from contexts where women can choose their labour companions, where the birthing facility has space for labour companions, and where the tasks of birthing companions are related to emotional support for the mother. The decision makers point out that in their settings women do not have free choice over their labour companions, there is limited space in birthing facilities, and companions are expected to carry out different tasks. These three factors are not necessarily common to high or middle income countries and thus were not covered in the subgroup analysis.
By identifying these specific transferability factors early in the review process (rather than simply comparing high vs. middle-income contexts), the review authors could have extracted data related to choice of labour companions, physical space in birthing facilities and tasks of labour companions from the included studies. They could have then conducted a subgroup analysis using the three factors discussed above which may have indicated different (degrees of) effects in different contexts. The decision makers would then have been better able to interpret and/or implement the intervention to their own context. This is a fictionalized example of a review finding from a qualitative evidence synthesis conducted by Bohren and colleagues (2019).
b. Document describing the background, review question, PICO (Population, intervention, comparison, outcomes), and inclusion criteria for a fictionalized adaptation of a systematic review.
We sent the latter document to the stakeholder participants. See supplementary material for the documents that were sent to participants.

| Collaborative meeting scenarios
We designed scenarios to resemble a typical meeting between review authors and stakeholders at the beginning of a systematic review process, with two systematic review authors and two decision makers from a Norwegian directorate. We instructed people to participate from the perspective of their assigned role (review author or stakeholder). For each meeting, we assigned one of the two following systematic review question to be discussed: 'Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children' (Gibson et al., 2017) and 'Perceptions and experiences of labour companionship: a qualitative evidence synthesis' (Bohren et al., 2019). We chose these two reviews as they examined interventions that we deemed relatively familiar for most people, and due to their social nature, could be influenced by context.
We assigned the effectiveness review to groups with authors who had experience synthesizing quantitative data, and the qualitative review to authors with experience synthesizing qualitative data.
We held the meetings at the Norwegian Institute of Public Health. Our involvement was limited to providing an introduction, observing the meeting, and clarifying terms or concepts when necessary. We audio-recorded and transcribed group user tests 2, 3 and 4.
The introduction included a description of the TRANSFER approach, the group user test method our research aims, and a question/answer session. Participants received and signed informed consent forms that gave us permission to use their feedback for improving TRANSFER and for research publication. Review authors led the simulated meeting according to steps in the guidance we provided beforehand: (1) briefly summarize the review question, and; (2) use the conversation guide to discuss possible factors that could influence the transferability of systematic review findings to the context specified in the review question, and the local (Norwegian) context. The first part of the TRANSFER approach, defining the PICO and review question, was not included in the group user test due to time restrictions.

| Think aloud approach
We employed a 'concurrent think aloud' approach whereby participants were encouraged to verbalize their thoughts at the same time working through the conversation guide together (Richardson et al., 2017). This involved each person reflecting their thoughts out loud as the group went through the various steps. During the semi-structured interviews, we employed a retrospective think-aloud technique, where participants drew on their memory of what had just transpired in the meeting.

| Observation
At least one researcher observed and made notes in each of the user tests.

| Feedback forms
Immediately following the meetings, participants filled out feedback forms. See Supporting Information: Appendix 2 for a copy of the feedback form used. The feedback forms were intended to reflect the facets of user experience from an adjusted version of Morville's Honeycomb model (see Table 2) (Rosenbaum, 2010).

| Semi-structured interviews
We interviewed the review author participants immediately after they filled out feedback forms. We chose to only interview review authors because we wanted to understand how they experienced using the conversation guide to lead the meeting. We conducted semi-structured interviews as they are a suitable method for exploring a set of known topics while allowing participants to raise new issues (Drever, 1995). At least one researcher observed the interviews. We audio-recorded some of the sessions. The topics of the interview guide reflected the facets of user experience from an adjusted version of Morville's Honeycomb model (see Table 1) (Rosenbaum, 2010). See Supporting Information: Appendix 3 for the interview guide.

| Real-life meeting observations
In addition to the group user tests, we also applied TRANSFER to a real-life review process. Here, a research team (led by a colleague that had participated in a user test) that was in the process of planning a review invited one of the authors (H. M. K.) to help prepare a stakeholder meeting using the TRANSFER approach conversation guide to discuss context. The researcher provided pre-meeting guidance and conducted non-participatory observation of the meeting and took notes.

| Analysis
We transcribed the audio-recordings of interviews. A third party transcribed the audio-recordings of two of the meetings and one researcher checked them for accuracy. We analysed data using the framework analysis method (Ritchie & Lewis, 2003). We used an a priori template of codes based on an adapted version of Morville's honeycomb model of user experience (minus the facets accessibility and value, which we deemed to be premature at this stage in the development of TRANSFER; see Table 3) as the basis for analyzing T A B L E 2 Facets of user experience according to an adjusted version of Morville's Honeycomb model (Rosenbaum, 2010)  the user experience of the conversation guide (Boyatzis, 1998;Crabtree & Miller, 1999) (Rosenbaum, 2010;Morville, 2004;Fereday & Muir-Cochrane, 2006). Through our analysis we identified many findings related to stakeholder engagement and other aspects of the meeting scenario that did not fit into the honeycomb model. We decided to use thematic analysis to organize these findings into themes (Boyatzis, 1998).
Two researchers coded each of the documents. We discussed all of the codes and themes until consensus was reached. We did not need to bring in a third researcher to settle any disagreements. We actively looked for examples of contrasting and discrepant participant opinions/experiences. All of the data were coded and analysed in their original language. We translated quotations for use in this article.

| FINDINGS
We identified a number of themes from the analysis of the group user tests which we have organized into the following broad categories: findings related to the user experience of the TRANSFER conversation guide, observations and experiences of stakeholder collaboration, participants' experiences unpacking the concepts 'transferability' and 'context', and results of the meeting scenarios. We also present findings related to our observation of the application of TRANSFER in a systematic review process. We will begin by presenting an overview of the participants.

| Participant profiles
We included 17 participants in four group user tests conducted in Norway in 2018 and 2020. See Table 3 for an overview of relevant participant characteristics. For the remainder of this paper, participants refers to either stakeholders or review authors. In three of the group user tests the stakeholders were decision makers from Norwegian governmental departments that often commission systematic reviews and/or are involved in guideline processes health and social services. In one group user test, we were unable to engage real decision makers, so three review authors played the role of stakeholders. We will still refer to these participants as stakeholders throughout the findings section.
One of the review authors was familiar with the concept of the TRANSFER approach, and two review authors had been involved in the development of the approach, but did not have experience using the conversation guide. Three of the eight stakeholders had taken part in an earlier iteration of the TRANSFER approach but indicated to the research team that their experience with or knowledge of TRANSFER felt insignificant.

| Findings related to users' experience of the TRANSFER conversation guide
In this section, we describe the users' experience of the TRANSFER conversation guide. We begin by describing general impressions and summarizing participants' feedbacks with a selection of quotes to illustrate their experiences. We then present a table that organizes participants' feedback into themes using a modified version of Morville's honecomb model (see Table 4) (Rosenbaum, 2010 Participants' suggestions for improving the guide included offering more examples and explanations for each potential factor, giving more detailed instructions, making the guide more flexible, adding a glossary of terms and including a more in-depth discussion of the review question before embarking on the conversation guide. In Table 4 we present an overview of the findings related to users' experience of the TRANSFER conversation guide organized in accordance with a modified version of Morville's honeycomb model (Rosenbaum, 2010).

| How participants experienced stakeholder collaboration
In this section, we describe our observations of, and participants' own expressed experiences with, stakeholder collaboration during the simulated meeting. All participants actively participated in the meeting scenarios.
Although the review authors usually led the discussions, there were instances where a stakeholder took initiative to move to the next factor in the conversation guide. One stakeholder expressed that they wished they had also received the conversation guide in advance, a document we thought would only be of interest to the review authors.
One participant noted that it could be valuable to include other types of stakeholders (such as practitioners) in meetings because their points of view could improve the usefulness of the conversation around context.
Although stakeholder collaboration is generally acknowledged in the literature as critical to the production of systematic reviews within informed decision making (Innvaer et al., 2002;Oliver et al., 2014;Tricco et al., 2016), one review author questioned that assumption: [The conversation guide] can create a better dialogue with stakeholders, but is it a research question whether that is in fact useful in the end? (review author, interview after user test 2).
Participants also suggested that other aspects of the systematic review production might benefit from stakeholder collaboration at the beginning of the review process. A number of participants indicated that the conversation guide and meeting could help improve the way they considered the review question, the inclusion criteria, the subgroup analyses, interpret the results and possibly support GRADE/-CERQual assessments: Chaos during this meeting leads to a clearer PICO and review question … the PICO refinement is really valuable (review author, user test 1 meeting scenario).
We have a project with vague inclusion criteria but

| Participants' experiences unpacking context and transferability
One of the aims of the TRANSFER approach is to provide guidance to review authors on how to systematically and transparently consider contextual factors that may influence the transferability of review findings. Our data showed how TRANSFER could support this process, while uncovering some of the areas where people struggled.

| Getting past assumptions to more fine-tuned understandings
Context may mean different things to different people. TRANSFER provides an explicit definition: 'the multi-level environment (not just the physical setting) in which an intervention is developed, implemented and assessed: the circumstances that interact, influence and even modify the implementation of an intervention and its effects' (Munthe-Kaas et al., 2020). Attention is directed to the specific factors related to the implementation environment, and not just the country or setting as a whole (e.g. Norway is not a contextual factor, but the multi-party political system present in Norway could be a contextual factor).
We observed that the conversation guide often helped participants to steer away from generalizations such as 'Scandinavia is different than the United States of America' and focus on how two contexts may differ specifically.
We should be focusing on the transferability of a study context to our context-not from one country to another (review author, user test 1).
Although participants often used examples of how another country may be different from their own context, they did this with respect to a specific transferability factor. In this example the participants were discussing if health or social welfare systems could influence transferability: And here the outcome will be that you have to pay out of pocket to go to the doctor, or be covered by insurance.
Like in the USA for example it can be really expensive to go to the doctor versus in Norway where it is almost free (review author, user test 3 meeting scenario).
Participants also pointed out that context may not always be important: The difference between an intervention lasting three or six weeks in Italy is the same as it lasting three or six weeks in Norway, it is the same with frequency (review author, user test 1 meeting scenario).
Several participants appeared to acknowledge that contexts could be conceived of as much narrower than the country level: You have a high-income setting, but a study can come from a much more narrow geographical area like the Bronx that has certain characteristics, or other times it is wider, for example the whole of New York City. Then you will get a lot of different There were, however, concerns that the conversation guide terminology and subcategories were not completely tailored for application to qualitative research. This is a very effectiveness review-list, and we're answering more qualitative … so words like 'compliant' and 'intervention' (stakeholder, user test 4 meeting scenario).

| Summarizing the meeting scenarios
In this section we describe two issues related to the results of the meeting scenarios. First, we discuss challenges we observed related to the hypothetical nature of the simulated meetings.

| Presentation and comparison of the results of the meeting scenarios in each user test
We present an overview of the individual meeting scenarios in Table 5. Generally, we observed much variation in how the meeting scenarios were conducted. Despite discussing the same review question (in three of four scenarios), and having comparable professional backgrounds (i.e. review authors or decision makers), the results of the meeting scenarios differed with respect to:

| Observation of application of TRANSFER in a systematic review process
As previously described, we also applied TRANSFER to a real-life setting. When we compare the findings from the user tests with the real-life example, we notice a number of key differences:

| DISCUSSION
This is one of the few studies we are aware of that attempts to explore the perceived value of a specific approach for engaging with stakeholder and evaluates guidance for review authors on how to engage with stakeholders (Esmail et al., 2015). The findings from this study emphasize the potential value of discussing the review question before beginning a discussion on transferability and context. Such a discussion could help to ensure a common understanding of the review question, PICO, inclusion criteria and the decision makers' context among review authors and stakeholders before the review process commences.
Although the meetings scenarios resulted in different lists of prioritized factors, there were some similarities across the groups. Furthermore, participants in this study were generally positive towards using a structured approach to discussing transferability and context in collaboration with stakeholders.

| Considering context and transferability
When provided with a list of transferability factors to consider, review authors and stakeholders are able to discuss context in a more thoughtful and nuanced manner, moving beyond country level to

4.
Presence of co-existing/alternative interventions

5.
Outcomes-defined and measured differently, length and intensity of follow-up 4 5 systematic review authors (2 playing role of stakeholders) What are the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders who have experience with a labour companion?

1.
Is the institutional support for having access to companions similar to that in Norway (are policies and culture in place)?

2.
Are the tasks expected of the companions similar to those that the Norwegian companions would carry out?

3.
Are the physical conditions similar for companions?

4.
Are the companions similar to companions found in Norway?
MUNTHE-KAAS ET AL. actually defining what it is that may make studies from a certain context less transferable to another context. Such a considered approach to context would hopefully facilitate the use of review findings by decision makers by producing reviews that are more useful and relevant for a decision makers' context (Innvaer et al., 2002;Oliver et al., 2014;Tricco et al., 2016). Additionally, such a systematic and transparent consideration of context may be able to inform assessments of the GRADE/-CERQual domains of indirectness and relevance. Some papers have suggested using a Delphi approach as a means to collaborate with stakeholders and collect information on transferability from stakeholders (Nasser et al., 2012;Wang et al., 2006).

| Stakeholder collaboration
Stakeholder collaboration in itself is widely regarded as an important way to ensure the use of systematic review findings in informed decision making (Innvaer et al., 2002;Oliver et al., 2014;Tricco et al., 2016). Findings from this study indicate that collaboration between review authors and stakeholders could lead to a more clearly defined review question and to a more structured discussion of potential transferability factors. Furthermore, a structured approach to stakeholder collaboration may encourage more active stakeholder participation by creating a space where it becomes evident to the stakeholder that their expertise is valuable, appreciated and has the potential to improve the relevance of the systematic review findings to their decisionmaking context. Such stakeholder participation may not only affect the actual relevance of the review findings, but may also potentially influence the stakeholder's perception of the relevance of the review findings.

| Improving user experience of the TRANSFER conversation guide
Although participants were generally positive towards the use of the synthesis can provide a greater understanding of a phenomenon than a single primary study (Hammersley, 1992). However, as with reviews of effectiveness, it is important to consider and assess factors that could influence the transferability of review findings to a decision-making context.
Moreover, the participants proposed that identified transferability factors could also be used to inform inclusion criteria and the sampling strategy in a synthesis. There appear, however, to be three important issues to explore before incorporating TRANSFER into reviews of qualitative evidence: First, how does the TRANSFER approach fits within the GRADE-CERQual Approach (Lewin et al., 2015). Second, how could TRANSFER fit with qualitative syntheses that use more interpretive synthesis methods. Third, how can the language in the conversation guide be adapted for use with qualitative research.

| Challenges related to group user testing
The advantage of involving multiple participants in each group user test was that it more closely resembled a meeting between review authors and stakeholders. The 'think aloud' protocol was also considered particularly useful as it allowed us more insight into the individual thoughts of each participant within the group, and not just the overall interaction between participants.
A drawback of involving multiple participants in a group user test, however, is that it was difficult and time consuming to transcribe the data, and analyse the findings. Furthermore, it was very difficult to compare and contrast between group user tests with different participants because the discussions were very connected to the dynamics of the specific group of participants.
We also encountered challenges related to the nature of group user tests more generally. It was difficult to recruit participants; therefore in one session review authors took on the role of stakeholders, rendering that data less representational and therefore weaker. During the group user tests, participants were often frustrated or confused due to the unfamiliarity of the review question being discussed, and participants did not prepare in the way that (we hope) they would for a real meeting with stakeholders.

| Observing application of TRANSFER in a systematic review process
Few of the challenges related to the TRANSFER conversation guide that we uncovered during the group user tests were present when we observed the application of TRANSFER In a systematic review process. This indicates that many of the issues that arose during group user tests may be addressed by better preparation of the review authors adapting the conversation guide to the topic and participants, and discussing a topic that is relevant for the participants.

| Future research
The findings from these user tests resulted in substantial changes to the format and language used in the TRANSFER Conversation guide (see above). We also realized the importance of including a discussion of the review question at the beginning of the meeting. We would like to test the refined version of the conversation guide, well as the PICO template with a wider range of review authors and stakeholders (e.g., different languages, settings, topical background, and experience levels). We would also like to continue observing the use of the TRANSFER approach in systematic review processes.
Some of the findings from this study can be used as evaluation measures in future studies to evaluate the experience and/or effect of stakeholder participation. For example, future studies could explore: • The perceived benefits and challenges of a structured approach to stakeholder collaboration • How the results of the TRANSFER approach are used in decisionmaking after reviews are completed (e.g., compare how decision makers perceive the usefulness and/or relevance of reviews findings from reviews with and without the TRANSFER approach) • Similarities and differences in which transferability factors are prioritized for a specific review question between groups of review authors and stakeholders from different contexts • Other uses for the TRANSFER approach, such as informing inclusion criteria, supporting GRADE assessments of indirectness or GRADE-CERQual assessments of relevance.

| Researcher's role
The data for the study was collected and analysed by two researchers (the two first authors) who developed the TRANSFER approach. The researchers are experienced systematic review authors, familiar with conducting both reviews of effectiveness and qualitative research. At the time of the user tests, the researchers were colleagues of, or had previously engaged with most of the participants (review authors and stakeholders) at some point before the user test.
Our involvement in developing TRANSFER and familiarity with some of the participants may have influenced both the feedback given by participants, and how we analysed the data.
On the other hand, our intimate knowledge of the TRANSFER approach put us in a unique position to understand: (a) where the conversation guide fell short of its intended aims, and (b) the nature of the participants' misunderstandings or problems.
Likewise, participants' familiarity with us may have reduced the stress they felt while using a tool for the first time under observation.

| Strengths and limitations
The strengths of this study are the use of multiple methods of data collection to triangulate data, the meeting scenario was organized to resemble a real meeting between review authors and stakeholders, and the use of the honeycomb model of user experience to interpret the findings. Furthermore, by including findings from our observation of a real-life application of the TRANSFER approach in this study, we are able to explore which of the challenges identified in our analysis may be related to user testing rather than the TRANSFER approach. However, this study has the following limitations: -A small number of user tests.
-Homogeneity among participants: Participants all came from the same geographical area, with review authors from the same institution.
-Simulated meeting scenarios, resulting in use of topics that participants were not necessarily experts in, and people not preparing for the meeting as much as they otherwise likely would have.
-The first part of the TRANSFER approach, defining the PICO and review question, was not included in the group user test due to time restrictions. 6 | CONCLUSION 6.1 | Implications for practice The findings from this study indicate that review authors and stakeholders may find a structured approach to collaboration beneficial when considering context and transferability of review findings. The results of such structured discussions with stakeholders may be included in a systematic review to: • provide rationale for inclusion criteria and subgroup analyses; • discuss issues related to transferability; and, • support GRADE/-CERQual assessments of indirectness and relevance.
The goal of the TRANSFER approach, as well as the concepts context and transferability need to be clarified for review authors and stakeholders intending to use the TRANSFER approach. The TRANSFER conversation guide needs to be modified with respect to format and language to improve user experience. Furthermore, meetings with stakeholders are likely to be more productive when review authors are familiar with the conversation guide, and all participants are adequately prepared for the meeting.
Using a conversation guide when collaborating with stakeholders may lead better collaboration between review authors and clients, better review questions, clearer inclusion criteria and improved consideration of context. The TRANSFER approach conversation guide appears to be equally relevant for review teams undertaking qualitative evidence synthesis and reviews of effectiveness.

AUTHORS' CONTRIBUTIONS
H. M. K. conceived of and designed the study, conducted the user testing, data analysis and interpretation of the results and drafted the manuscript. H. N. helped design the study, recruited participants, conducted the user testing and gave feedback on the data analysis, interpretation and the manuscript. User tests 2, 3 and 4 were transcribed using a professional service. S. R. advised on the study design and conduct. All authors read and approved the final manuscript.